CBT Today: keeping up with the literature - exposure, mindfulness & reappraisal - winter '13/14 (2nd post)
Last updated on 28th August 2014
In yesterday's post on "Keeping up with the literature", I wrote about the wealth of updated knowledge that has emerged with publication of the third UK National Survey of of Sexual Attitudes and Lifestyles (Natsal) and about useful qualitative research on why most health professionals (including psychotherapists) tend to be poor at providing help for sexual difficulties. I would now like to say a little about some new findings in exposure therapy, and some additional insights into mindfulness, relaxation & reappraisal.
There have been a series of fascinating recent papers on exposure treatments. Abramowitz in his freely downloadable article "The practice of exposure therapy: Relevance of cognitive-behavioral theory and extinction theory" comments that "Exposure therapy is the most effective psychological intervention for people with anxiety disorders" and argues that "knowledge of the relevant theory is crucial to being able to implement exposure therapy in ways that optimize both short- and long-term outcome." Leer et al, in "Eye movements during recall of aversive memory decreases conditioned fear", give the best explanation that I've read so far on why Eye Movement Desensitization & Reprocessing (EMDR) therapy is effective. The Wikipedia article on EMDR comments that development of this approach was triggered by the originator Francine Shapiro's personal observation that voluntary eye movements reduced the emotional distress associated with recall of disturbing memories. In a laboratory study, Leer & colleagues carefully document this process & argue that "Contemporary learning theory suggests that treatment may be optimized by adding techniques that aim at revaluating the aversive consequence (US) of the feared stimulus. This study tested whether US devaluation via a dual task - imagining the US while making eye movements - decreases conditioned fear ... Dual tasking, relative to the control condition, decreased memory vividness and emotionality. Moreover, only in the dual task condition reductions were observed in self-reported fear, US expectancy, and CS unpleasantness, but not in skin conductance responses. Findings provide the first evidence that the dual task decreases conditioned fear and suggest it may be a valuable addition to exposure therapy."
Other interesting recent exposure-focused articles include the cutting edge Anderson et al study "Virtual reality exposure therapy for social anxiety disorder: A randomized controlled trial", the practical, freely-downloadable-in-full-text, Ehlers et al report "Implementation of cognitive therapy for PTSD in routine clinical care: Effectiveness and moderators of outcome in a consecutive sample", the thoughtful Bryant et al study "Augmenting cognitive behaviour therapy for post-traumatic stress disorder with emotional tolerance training", the revisionary Kliem & Kroger paper "Prevention of chronic PTSD with early cognitive behavioural therapy. A meta-analysis using mixed-effects modeling", the helpful Ljotsson et al insight "Mechanisms of change in an exposure-based treatment for irritable bowel syndrome", and the intriguing therapeutic (and parenting) implications of Golkar et al's paper "Other people as means to a safe end: Vicarious extinction blocks the return of learned fear" with its abstract commenting "Information about what is dangerous and safe in the environment is often transferred from other individuals through social forms of learning, such as observation. Past research has focused on the observational, or vicarious, acquisition of fears, but little is known about how social information can promote safety learning. To address this issue, we studied the effects of vicarious-extinction learning on the recovery of conditioned fear. Compared with a standard extinction procedure, vicarious extinction promoted better extinction and effectively blocked the return of previously learned fear ... Our results confirm that vicarious and direct emotional learning share important characteristics but that social-safety information promotes superior down-regulation of learned fear."
There are also half a dozen new studies I would like to briefly mention in the general area of mindfulness, reappraisal, relaxation and attention training. Well ... Bunnell et al's paper "A randomized trial of attention training for generalized social phobia: Does attention training change social behavior?" pretty much kicks into touch any notion that thorough, but straightforward, attention training is of much therapeutic use on its own in social phobia treatment - although I still believe that encouragement for task focus rather than self focus may be beneficial. In contrast, the effectiveness, but lack of difference, between currently popular mindfulness-based training and more traditional relaxation approaches for GAD - "A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder" underlines the value of NICE-recommended applied relaxation training and presumably helped motivate the authors' interesting discussion in their linked paper "A contemporary view of applied relaxation for generalized anxiety disorder." So maybe there's less difference in both the effectiveness and underlying mechanisms of relaxation training and mindfulness than we have thought. In a similar way differences between the very helpful ... but apparently very distinct ... approaches involving mindfulness or cognitive restructuring/reappraisal turn out to be less definite than one might have naively supposed. So Wolgast et al. write - in their paper "Cognitive restructuring and acceptance: An empirically grounded conceptual analysis" - "The study explores the constructs of cognitive restructuring and acceptance using items from well-established measures of the respective constructs in order to determine what subcategories or conceptual nuances that could be empirically detected, and examines these factors' relationship to each other and to positive and negative emotionality, quality of life and clinical status ... In sum, the findings from the study indicate that acceptance and cognitive restructuring should not be regarded as unitary and non-related constructs, but rather as partly overlapping general dimensions of emotion regulation consisting of several sub constructs or conceptual nuances with somewhat different psychological functions and properties."
Keng et al. - in "Reappraisal and mindfulness: A comparison of subjective effects and cognitive costs" - appear to come up with a potentially important distinction between reappraisal and mindfulness when they report "The present study investigated the relative effects of mindfulness and reappraisal in reducing sad mood and whether trait mindfulness and habitual reappraisal moderated the effects. The study also compared the extent to which implementation of these strategies incurred cognitive resources ... Results showed that mindfulness and reappraisal were superior to no training, and equivalent in their effects in lowering sad mood. Compared to mindfulness, reappraisal resulted in significantly higher interference scores on a subsequent Stroop test, reflecting greater depletion of cognitive resources ... The study suggests that although mindfulness and reappraisal are equally effective in down-regulating sad mood, they incur different levels of cognitive costs." However I suspect this difference in cognitive cost might dwindle or disappear if one paired the reappraisal with a hobby horse of mine - brief training in implementation intentions. Varley et al - in "Making self-help more helpful" - provide just one of a series of recently published studies illustrating the value of using implementation intentions more widely. And the final paper I'll mention in this "Keeping up with the literature" gallop is Troy et al's "A person-by-situation approach to emotion regulation: Cognitive reappraisal can either help or hurt, depending on the context" with its warning "Emotion regulation is central to psychological health. For instance, cognitive reappraisal (reframing an emotional situation) is generally an adaptive emotion-regulation strategy (i.e., it is associated with increased psychological health). However, a person-by-situation approach suggests that the adaptiveness of different emotion-regulation strategies depends on the context in which they are used. Specifically, reappraisal may be adaptive when stressors are uncontrollable (when the person can regulate only the self) but maladaptive when stressors can be controlled (when the person can change the situation). To test this prediction, we measured cognitive-reappraisal ability, the severity of recent life stressors, stressor controllability, and level of depression in 170 participants. For participants with uncontrollable stress, higher cognitive-reappraisal ability was associated with lower levels of depression. In contrast, for participants with controllable stress, higher cognitive-reappraisal ability was associated with greater levels of depression. These findings support a theoretical model in which particular emotion-regulation strategies are not adaptive or maladaptive per se; rather, their adaptiveness depends on the context." All trainers using reappraisal, relaxation and particularly mindfulness take note. Maybe the apparently adverse effects of teaching mindfulness to those with a history of only a few depressive episodes were genuine findings rather than just aberrations due to low patient numbers - see Teasdale et al (2000) and Ma & Teasdale (2004)!?